This is an official
CDC HEALTH ADVISORY

Summary:

The first case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in the United States, identified in a traveler, was
reported to CDC by the Indiana State Department of Health (ISDH) on May 1, 2014, and confirmed by CDC on May 2. The patient is in a
hospital in Indiana after having flown from Saudi Arabia to Chicago via London. The purpose of this HAN is to alert clinicians, health
officials, and others to increase their index of suspicion to consider MERS-CoV infection in travelers from the Arabian Peninsula and
neighboring countries. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care
physicians, and infection preventionists, as well as to emergency departments and microbiology laboratories.

Background:

The first known cases of MERS-CoV occurred in Jordan in April 2012. The virus is associated with respiratory illness and high death
rates, although mild and asymptomatic infections have been reported too. All reported cases to date have been linked to six countries in
the Arabian Peninsula: Saudi Arabia, Qatar, Jordan, the United Arab Emirates (UAE), Oman, and Kuwait. Cases in the United Kingdom,
France, Italy, Greece, Tunisia, Egypt, and Malaysia have also been reported in persons who traveled from the Arabian Peninsula. In
addition, there have been a small number of cases in persons who were in close contact with those infected travelers. Since mid-March
2014, there has been an increase in cases reported from Saudi Arabia and UAE. Public health investigations are ongoing to determine the
reason for the increased cases. There is no vaccine yet available and no specific treatment recommended for the virus. In some cases, the
virus has spread from infected people to others through close contact. However, there is currently no evidence of sustained spread of
MERS-CoV in community settings. Additional information is available at: http://www.cdc.gov/coronavirus/mers/index.html.

Recommendations:

Healthcare providers should be alert for and evaluate patients for MERS-CoV infection who

develop severe acute lower respiratory illness within 14 days after traveling from countries in or near the Arabian Peninsula,
excluding those who only transited at airports in the region; or

are close contacts of a symptomatic recent traveler from this area who has fever and acute respiratory illness; or

are close contacts of a confirmed case.

For these patients, testing for MERS-CoV and other respiratory pathogens can be done simultaneously. Positive results for another
respiratory pathogen (e.g H1N1 Influenza) should not necessarily preclude testing for MERS-CoV because co-infection can occur.

Clusters of patients with severe acute respiratory illness (e.g., fever and pneumonia requiring hospitalization) without recognized links
to cases of MERS-CoV or to travelers from countries in or near the Arabian peninsula should be evaluated for common respiratory
pathogens. If the illnesses remain unexplained, providers should consider testing for MERS-CoV, in consultation with state and local
health departments. Healthcare professionals should immediately report to their state or local health department any person being
evaluated for MERS-CoV infection as a patient under investigation (PUI). Additional information, including criteria for PUI are at:
http://www.cdc.gov/coronavirus/mers/interim-guidance.html.
Healthcare providers should contact their state or local health department if they have any questions.

Persons at highest risk of developing infection are those with close contact to a case, defined as any person who provided care for a
patient, including a healthcare provider or family member not adhering to recommended infection control precautions (i.e., not wearing
recommended personal protective equipment), or had similarly close physical contact; or any person who stayed at the same place (e.g.
lived with, visited) as the patient while the patient was ill.

Healthcare professionals should carefully monitor for the appearance of fever (T> 100F) or respiratory symptoms in any person who has
had close contact with a confirmed case, probable case, or a PUI while the person was ill. If fever or respiratory symptoms develop
within the first 14 days following the contact, the individual should be evaluated for MERS-CoV infection. Ill people who are being
evaluated for MERS-CoV infection and do not require hospitalization for medical reasons may be cared for and isolated in their home.
(Isolation is defined as the separation or restriction of activities of an ill person with a contagious disease from those who are
well.). Providers should contact their state or local health department to determine whether home isolation, home quarantine or
additional guidance is indicated since recommendations may be modified as more data becomes available. Additional information on home
care and isolation guidance is available at: http://www.cdc.gov/coronavirus/mers/hcp/home-care.html. Healthcare providers
should adhere to recommended infection-control measures, including standard, contact, and airborne precautions, while managing
symptomatic contacts and patients who are persons under investigation or who have probable or confirmed MERS-CoV infections. For CDC
guidance on MERS-CoV infection control in healthcare settings, see Interim Infection Prevention and Control Recommendations for
Hospitalized Patients with MERS-CoV at: http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html.

For suspected MERS-CoV cases, healthcare providers should collect the following specimens for submission to CDC or the appropriate state
public health laboratory: nasopharyngeal swab, oropharyngeal swab (which can be placed in the same tube of viral transport medium),
sputum, serum, and stool/rectal swab. Recommended infection control precautions should be utilized when collecting specimens. Specimens
can be sent using category B shipping containers. Providers should notify their state or local health departments if they suspect
MERS-CoV infection in a person. State or local health departments should notify CDC if MERS-CoV infection in a person is suspected.
Additional information is available at: http://www.cdc.gov/coronavirus/mers/guidelines-clinical-specimens.html.

Additional or modified recommendations may be forthcoming as the investigation proceeds.

For more Information:

For more information, for consultation, or to report possible cases, please contact the CDC Emergency Operations Center at (770)
488-7100.

The Centers for Disease Control and Prevention (CDC) protects people’s health and safety by preventing and controlling diseases
and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through
strong partnerships with local, national, and international organizations.

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